Description
Our patient with ccTGA had previously undergone VSD patch closure and
pulmonary valvotomy as an infant and then later palliated with pulmonary
artery banding. He subsequently developed worsening heart failure and
was listed for heart transplantation due to progressive systemic RV
failure. Following ring annuloplasty of the systemic tricuspid valve, we
proceeded to systemic RVAD implantation. As per routine, placement of
the HM3 inflow cannula to the RV apex was guided by transesophageal
echocardiography (TEE) but optimal image acquisition was challenging.
The inflow cannula was to be placed anterior and lateral to the true
apex of the systemic RV. The ventriculotomy created by the VAD coring
device overrode into the ventricular septum and was hidden underneath
the inflow cannula ring (Fig 1A). With initiation of RVAD at 4L/min, the
patient became severely hypoxic with a PO2 of 45-50 mmHg
secondary to the large pulmonic to systemic circulation shunt (i.e
right-to-left) which was also identified on TEE and epicardial
echocardiogram. Cardiopulmonary bypass (CPB) was re-initiated and the
inflow cannula was removed, revealing a large iatrogenic VSD at the
cannula insertion point (Fig 1A ). The VSD was closed by bovine
pericardial patch and the ventriculotomy was extended laterally to
relocate the new RVAD sewing ring (Fig 1B ) using 2-0 Tycron
sutures placed as an open technique. After CPB was weaned again, the
patient initially remained cyanotic and echocardiography imaging
identified a tiny residual VSD patch leak with right to left shunting as
a potential cause of hypoxia. Due to the prolonged duration and
complexity of the case, pursuing residual VSD closure was deemed unsafe.
A trial of rescue of inhaled nitric oxide (iNO) was initiated which had
the dramatic effect of increasing the arterial saturation from the 70%
range to 90s. The patient was transferred back to the cardiovascular
intensive care unit in stable condition and continued to demonstrate
oxygen saturations >90%, even after weaning iNO and
extubation from mechanical ventilation. There were no further issues
with regards to either VAD support or saturations for our patient after
surgery, and the patient was successfully bridged to transplant after 91
days of RVAD support.